How HMO Works -- The Referral Process

How HMO Works -- The Referral Process

Referrals are an important part of saving money when you have an HMO. You’ll want to know when you need a referral and how to use your HMO benefits.

When you sign up for an HMO, your first step is to pick a primary are physican (PCP) to manage your care. You may already have a PCP, such as your family doctor. A child’s pediatrician and a woman’s OB/Gyn  can also act as their PCP.

Your PCP will make sure you get the care you need, even when you see another doctor or go to the hospital. When you have a health issue, you’ll first go to your PCP.

You don't need a referral to see a specialist who is in the MT Blue Focus POSSM network. For specialists not in the network, your PCP will need to get a referral approved before your specialist visit.

The PCP will:

  • turn in a referral, if needed
  • work with your insurer to get a referral approved
  • monitor what is diagnosed and what care you get from the specialist
  • turn in any additional referrals needed

When the specialist’s office calls to arrange your visit, ask if they are in your plan’s network. If the specialist plans a lot of tests or procedures, ask if they have checked to make sure all are covered.

If you are getting ongoing treatment for a health issue, ask your PCP about a standing referral. It allows you to see your specialist without needing a new referral for each visit. 

It’s your right to ask questions to make sure your doctors are using your HMO the right way. You’ll have higher costs if you see a provider who is not in your HMO’s network.   

You can get more information about your HMO health plan at any time. Just log in or register for your member account, Blue Access for MembersSM. Visit the My Coverage tab to verify your coverage and identify your medical group and PCP. 

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.

Originally published August 18, 2015; Revised 2020